Foot Problems in Runners

Millions of runners take to the streets, tracks and trails everyday. People run for health, for fitness, for stress relief and for fun. There are casual joggers, trail runners, sprinters, marathon runners and elite competitors. Despite these differences, all runners are susceptible to foot problems. Common foot and ankle conditions in runners include blisters, foot fungus, ankle sprains, stress fractures, tendonitis and plantar fasciitis. Fortunately, most of these conditions can be prevented and many are easily treated. But, when foot and ankle conditions are ignored they can become difficult to treat and can even become resistant to therapy.

Heel Pain - Plantar Fasciitis

One million runners will develop heel pain every year. The most common cause of heel pain is plantar fasciitis, which is the result of excess stress through a long ligament type structure (the plantar fascia) in the bottom of the foot. The excess stress causes tearing and results in inflammation and pain. The classic symptoms are pain in the heel at the first step in the morning, or upon rising after long periods of rest.

Runners may only experience the pain at the beginning of a run and many say that the pain will work itself out after about 1 mile, but then return by the end of a long run or at the end of the day. Runners develop plantar fasciitis and tendontis for a variety of reasons. One of the most common reasons for the development of plantar fasciitis is wearing poor quality or worn out shoes. It is common to grab old “mud” shoes to run in bad weather, or to start Spring training in shoes that were used the entire previous season. The older shoes may have a worn out midsole and may have lost all aspects of support and stability. Improper fit of a new running shoe can also cause fasciitis. Overtraining is another cause of plantar fasciitis. Adding too many miles too quickly, or adding too many hills too quickly can overstress the foot. Abnormal mechanics in the foot is another contributing factor to the development of plantar fasciitis in runners. If the foot overpronates (rolls in) this places a tremendous amount of stress on the tendons in the arch and on the plantar fascia, many times resulting in small microtears and hence plantar fasciitis.

The keys to treatment for plantar fasciitis and are rest, ice, stretching and support. Give your foot a break! Cross train with swimming or biking and avoid impact activity on your foot. If you must run, cut back on mileage, avoid hills and speed work and gently stretch before your run, but after a 10 minute warm-up. Ice the area for 20 minutes, after the run. Try to ice for 20 minutes, twice a day. Stretch the calf and/or the arch multiple times throughout the day. Make sure you start with gentle stretching, and avoid overstretching. For plantar fasciitis, night splints are very helpful. Buy supportive shoes and consider an over the counter orthotic or arch support. If you have flatfeet you may need custom made orthotics from a podiatrist. If this is a chronic problem, see your podiatrist.

Tendonitis

Achilles tendonitis and related calf problems are the most common injuries in runners. Pain develops at the back of the heel or in the calf and can be sharp with activity and feel deep and dull with rest. The pain may be apparent at the first step in the morning or rising after long periods of rest. Runners may experience sharp pain in the heel area at the beginning of a run which then becomes a dull annoyance during the run. In severe cases, it may be so painful that it will bring running to a halt. Calf injuries and Achilles tendonitis are both aggravated by hills and stairs. The steps to treat tendonitis are very similar to treating plantar fasciitis.

Stress Fractures

Stress fractures most commonly occur in the metatarsal bones. The metatarsal bones are the long bones in the middle of the foot. Although they can occur in the tibia (the leg bone) and be mistaken for shin splints. A stress fracture is an incomplete break of the bone. The pain is usually sharp and develops suddenly, but it is not the result of a specific injury or trauma. Stress fractures are more commonly the result of overuse. If you develop a sudden swelling and bruising on the top of your foot, but can’t remember any specific injury, it is time to see your podiatrist. The typical treatment is a surgical (fully rigid shoe) for 4-6 weeks. More information on stress fractures.

Ankle Sprains

Ankle sprains are another common injury in runners, especially trail runners. The most common ankle sprain is called an inversion ankle sprain. The ligaments on the outside of the ankle tear when the foot turns in and the ankle turns out. There are three ligaments that hold the ankle joint in place on the outside of the ankle. When the ankle is twisted, one or more of these ligaments may be torn. Most ankle sprains involve partial tearing of one or more ligaments. Severe ankle sprains involve partial to complete tears of two or three ligaments.

Very mild ankle sprains may only need an ace bandage and high top shoes for support for a week or two. For more moderate sprains, a lace-up ankle brace and sometimes an aircast are necessary. If there is a considerable amount of swelling, bruising and pain, a visit to the doctor is recommended. An evaluation will be done to assess the stability of the joint and X-rays will be taken to rule out a broken bone. Mild ankle sprains may only take a week or two for full recovery, but most ankle sprains will take about 6 weeks. More severe ankle sprains typically take 3 months and may not feel 90-100% for almost a year. If you experience a severe ankle sprain, consider a visit to a podiatrist. If you have not healed from an ankle sprain after 6 weeks, see a podiatrist. More information on ankle sprains.

Friction blisters

Friction blisters are one of the more common foot injuries in runners. Blisters most commonly develop on the back of the heel, the side of the big toe or on the toes. A blister is a result of friction or shearing forces on the skin. The blister is actually a defense mechanism of the body, which occurs when the shearing forces separate the outer layer of skin, the epidermis, from the deeper dermal layer of the skin. Fluid collects between these layers, providing a cushion against the aggravating force while a new layer of skin re-grows underneath. Blisters commonly develop under calluses and corns in between and at the tips of the toes.

The best treatment is prevention. Blisters can be prevented with the appropriate socks and proper shoe fit. Sometimes, blisters are unavoidable. Small blisters that are not painful and not infected, should be left alone. There is no need to pop and drain these blisters. The most important treatment is to reduce friction and look for the cause. Was the sock folded or crumpled at the toes or heel? Is there stitching in the shoe that is prominent or defective? Is the shoe not fitting properly. You can place moleskin directly on top of small blisters to help reduce friction. Drain larger blisters with a sterilized needle (unless you are diabetic) by punctured the side of the blister and placing gentle pressure with guaze to absorb the fluid. Don’t remove the top layer of skin. This layer is the body’s best protection. Dry the area, but don’t use antibiotic ointment over the area. Place moleskin directly over the blister if you plan to continue running. Pat dry with a towel after each shower and the moleskin should stay on for a number of days. Cut the edges of the moleskin if the corners peel up, but don’t pull off for at least 3 days. This will tear the top layer of skin off and create an open wound. Any blister that has redness, streaking or pus may be infected. You should see your doctor immediately.

Foot & Toenail Fungus

Fungus grows in moist, warm environments, which places runners, in particular, at risk. Foot fungus (tinea pedis) is characterized by peeling, redness and itching on the bottom of the foot and in between the toes. Foot fungus rarely causes pain or any considerable problems, but can be itchy, uncomfortable and can spread to the toenails. Foot fungus can be treated with over the counter anti-fungal medications in combination with anti-fungal powder and spray in the shoes and eliminating the moist, warm environment. More information on foot fungus.

Toenail fungus is characterized white, splotchy areas on the nail or thickness and yellow discoloration of part of the entire nail. Toenail fungus can cause ingrown nails and thickened nails, both of which can cause pain. Toenail fungus is much more difficult to treat. The treatments range from simple home remedies to expensive oral medications. Prevention is the best treatment. Decrease the amount of moisture by using wicking socks and make sure to have proper sock and shoe fit.

Shin Splints

The term shin splints is used to describe pain on the front of leg bone. The most common cause for this type of pain is inflammation of the sheath surrounding the leg bone (the tibia). This occurs as a result of traction forces from the leg muscles. The pain may be directly on the front of the leg bone, or more towards the inside of the leg bone. There is generally tenderness with direct palpation along the shin. The pain is aggravated by running, walking, short sprints and walking up and down stairs or hills. The pain is usually relieved with rest, but returns with activity. Medical names describing this condition include medial tibial stress syndrome and tibial periostitis. Other causes of pain in the area include compartment syndrome and tibial stress fractures.

The most common cause for shin splints is overuse. They commonly occur with Spring training or the addition of sprints or hill running. Faulty foot mechanics is another reason for the development of shin splints. Many runners and athletes have tight calf muscles and abnormal motion in their feet, in the form of pronation. More on tight calf muscles and overpronation.

Calf stretching will stretch some of the affected deep muscles in theback and side of the leg. It will take stress off of the muscles in the front of the leg which lift the foot up (dorsiflex). Calf stretching will also decrease overpronation.

Wearing supportive shoes is one of the most important steps you can take. A flexible shoe will only worsen the problem. A motion control shoe is ok if you have overpronation and don't wear orthotics or other motion control inserts.

Controlling overpronation is another important step. To assess if you have overpronation, a visit to your podiatrist or physical therapist is recommended. One of the best motion control prefabricated orthotics to control pronation is the Prolab P3 Orthotic. A motion control insert which is less rigid is the Superfeet Sport Insole.

Icing for 15-20 minutes after the activity, directly on the shin, will help reduce inflammation.

If you don't improve within a couple of weeks, make sure to see your doctor and have a tibial stress fracture or exercise induced compartment syndrome ruled out. More information on shin splints.

Nerve impingement

Pain, tingling and numbness on the top of the foot is a common problem resulting from a nerve impingement. A nerve impingement is commonly known as a “pinched nerve” or a nerve entrapment. The nerve is being irritated by structures within the foot or pressure from a shoe.

A nerve impingement at the ankle results in numbness, tingling and pain on the top of the midfoot. Sometimes the pain and tingling will extend to the toes. A history of ankle sprains or other previous trauma can make an individual prone to ankle nerve impingements because of the repetitive stretch injury to the nerve. Most nerve impingements are nerve injuries classified as neuropraxia, although in more severe cases axonotemesis may occur. More on nerve injury classifications.

A nerve impingement can also occur on the top of the foot and is most commonly due to compression from shoes. This is more common for individuals with a higher arch foot. Pain, tingling and numbness may occur on the top of the foot and extend into the toes. There may be a cord like “twang” when rubbing a finger over the top of the foot, which may be accompanied by a shooting, electrical pain. The images below show the common areas of distribution of symptoms, such as tingling, numbness and pain.

Treatment: Eliminating the contributing factors is the first step to treating a nerve impingement. Tight shoes or boots, compression stockings, elastic braces and other tight clothing could be contributing to the problem. Resting the foot and reducing the associated inflammation with ice and/or contrast soaks may be helpful. Placing a pad around the origin of the nerve impingement, can decrease pressure and rub from shoes. Horseshoe pads work well on the top of the foot. Shoe lacing techniques can help alleviate pressure and compression of the nerve. See our information page on shoe lacing techniques.

A short course of anti-inflammatory medications may be needed and if there is scar tissue buildup from a previous injury, physical therapy may be recommended. A steroid injection can decrease local inflammation. When conservative therapy fails, a surgical nerve decompression by may indicated.

Thick Toenails

Thick toenails are usually a result of repetitive trauma or fungus. Repetitive trauma means a repeated force or irritation. Repetitive trauma is common in runners, especially at the toes. While running, the foot has some movement, even in the best fitting shoe and the toes can rub up against the toebox of the shoe. This is more common in runners who do a lot of hill training. Going downhill typically results in the most repetitive trauma to the nails. Many times the nails become black or discolored, typically as a result of blood underneath the nails (termed subungual hematoma). Black toenails are very common in distance runners and hill runners. This can cause pain or may just be annoying. If at any time the thick or black toenails are associated with redness, swelling or pus, see your doctor immediately. Runners with toes that curl up naturally are more susceptible to shoe rubbing and irritation at the toes. Ill-fitting shoes are also a major culprit for the development of black or thick toenails. If the shoe is too large, the foot will have more movement and rub up against the toebox with each step. A shoe that is too tight, especially at the toe box, will result in a constant pressure on the toenails. Wearing socks that are too thick, cotton socks that ball up at the tips of the toes or contain too much moisture can also be a problem. The key to treatment is recognizing the problem. Avoiding hills or not running is not the answer, finding the correct combination of shoes and socks should make all the difference.

The Problem with Moisture

During any sporting activity, as much as one pint of perspiration can develop on each foot. That is a lot of sweat! It is extremely important for runners to have a sock and shoe combination which encourages wicking. Wicking is the ability of a substance to draw up against gravity. In this case it is the perspiration traveling from the feet, through the sock and shoe to evaporate. Without wicking, the foot and the sock will become wet. When a sock becomes wet, it loses it’s shape, can bunch at the heel, the arch or the toes and can increase shearing forces and friction. Socks will no longer act as a protection for your feet, but instead can be the cause of the plethora of foot problems. More information on wicking socks. More information on sweaty feet.

Shoe Fit

Finding the correct pair of running shoes can be an exercise in frustration. The market is flooded with running shoes, manufacturers regularly change the design of your favorite shoe and the sizes are not always interchangeable between companies.

Many runners cringe at the thought of shopping for running shoes. The importance of a proper fitting shoe can not be understated. Without proper fit, the runner will be more prone to not only blisters, but also foot conditions like tendonitis and plantar fasciitis. For a list of tips to use when shopping for running shoes, click here.

As in most cases, prevention is your best treatment. Proper shoe and sock fit, gentle stretching after warming up and recognizing a problem before it become serious are your keys to staying active and avoiding foot problems. More information on choosing shoes.

Disclaimer: The advice on this website is not intended to substitute for a visit to your health care provider. We will not be held liable for any diagnosis made or treatment recommended. Consult your doctor if you feel you have a medical problem.